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[00:00:00] Behind the Night, the Surgery podcast, relevant and engaging content designed to help you dominate the day.

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Today's topic is Adexo Emergencies, written by Mary Rina and recorded by Nick and Mary.

So you have a [00:02:00] 3-year-old gravitate two, para two. She's presenting today with progressively worsening lower abdominal pain over the last five days. Uh, this abdominal pain's been associated with nausea and some feelings of meles. She reports some vaginal discharge as well. Um, and reports a history of dysuria at home.

She's felt febrile, uh, but hasn't actually checked her temperature. Given these concerns, walk me through your diagnostic approach.

I approach this as suspected. Complication of PID or pelvic inflammatory disease and maybe with concern for a tubo ovarian abscess. I begin with a detailed history focusing on symptom duration progression, prior episodes of PID, recent sexual transmitted infections, or recent sexual activity contraceptive use, and any recent uterine instrumentation.

I specifically ask about gastrointestinal and urinary symptoms because these can overlap in obscure diagnoses. [00:03:00] On exam, I complete an abdominal exam assessing for tenderness to palpation or any guarding. Then I perform a pelvic exam with a speculum for evaluation of any discharge presence and assessing the appearance of the cervix.

After this, I would perform a bi-manual exam, assessing for cervical motion tenderness, uterine and adnexal tenderness. I obtain a pregnancy test to exclude ectopic pregnancy, and I may include labs including a CBC, and a inflammatory markers to assess systemic involvement. And then I would also perform cervical testing for gonorrhea and chlamydia.

Alright. What imaging are would you obtain and how would you interpret the findings?

I would obtain a transvaginal ultrasound as my first line imaging modality. I would assess for a complex edex L Mass with irregular thick walls, internal echoes, septations, and loss of normal ovarian architecture. I also evaluate for free fluid.

If my ultrasound findings are equivocal or if I'm [00:04:00] concerned about any sort of gastrointestinal pathology, I may proceed with a contrast enhanced CT scan as well to better define the extent of disease and adjacent organ involvement.

Okay. So once you've arrived at TOA as your diagnosis, what would you do or how would you determine your initial management?

Management for A TOA depends on clinical stability, menopausal status, abscess characteristics, and response to therapy. In a stable, premenopausal patient without signs of rupture or sepsis, I initiate broad spectrum IV antibiotics with close inpatient monitoring. I reassess the patient's pain, vital signs and laboratory trends over the next 48 to 72 hours.

Lack of improvement or worsening symptoms may prompt me to escalate to image guided drainage or potential surgical intervention.

Tell me more about when you might proceed with drainage or surgery.

I proceed with [00:05:00] interventions such as drainage or surgery when the patient fails to improve after adequate antibiotic therapy.

Um, or if the patient shows signs of clinical deterioration or has imaging features suggestive of rupture image guided drainage is preferred when feasible to preserve reproductive organs while surgery is indicated maybe for cases such as rupture, sepsis, or concern for malignancy.

Okay, let's switch gears now.

Let's say you have a 28-year-old patient who has sudden onset, severe right lower quadrant pain and vomiting. She denies any fever of vaginal discharge. Talk to me about your approach to this presentation.

For this particular presentation, I'm concerned for potential ovarian torsion, which I treat as a surgical emergency.

I rapidly assess pregnancy status, onset, and characteristics of pain and associated symptoms such as nausea or vomiting. I review prior imaging, no ovarian cyst. Fertility [00:06:00] treatments or pregnancy. On exam, I assess for focal tenderness and peritoneal signs, recognizing that exam findings can be minimal.

And sometimes for these patients, I proceed urgently with pelvic ultrasound to support the diagnosis, but I may not delay surgical intervention if clinical suspicion is high.

What ultrasound findings would support torsion? Um, and tell me further about what the limitations of ultrasound might be.

When I look in an ultrasound and suspect torsion of the ovary, I would see potential for ovarian enlargement, stromal edema, peripheral follicle displacement, and the twisted vascular pedicle.

When visible, I may interpret these ultrasound findings cautiously, particularly thinking about doppler flow because normal flow does not exclude torsion.

Okay. If you're suspecting torsion, how is it definitively diagnosed and then ultimately managed?

Definitive diagnosis of torsion is made [00:07:00] surgically.

Given the risk of irreversible ischemia, I proceed to urgent laparoscopy for detorsion. When torsion is suspected in reproductive age patients, I prioritize ovarian conservation whenever feasible.

Is there an instance where you might perform salpingo ectomy instead?

I may perform adnexal removal when the ovary is clearly non-viable or when malignancy is suspected, particularly if I'm operated in a post-menopausal patient.

Um, what is the overarching principle in managing acute adnexal pathology?

When I think about overarching principles for managing acute n exo pathology, whether that is uh, TOA or an ovarian torsion, I think about early recognition and timely intervention as being very critical delays in either increased morbidity, compromise fertility, and worsen outcomes for patients.

Be sure to listen [00:08:00] to Part B for high yield commentary and other tips and tricks

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Today's topic is Adexo Emergencies, written by Mary Rina and recorded by Nick and Mary. So you have a 3-year-old gravitate two, para two. She's presenting today with progressively worsening lower abdominal pain over the last five days. Uh, this abdominal pain's been associated with nausea and some feelings of meles.

She reports some vaginal discharge as well. Um, and reports a history of dysuria at home. She's felt febrile, uh, but hasn't actually checked her temperature. Given these concerns, walk me through your diagnostic approach.

I approach this as [00:09:00] suspected. Complication of PID or pelvic inflammatory disease and maybe with concern for a tubo ovarian abscess.

I begin with a detailed history focusing on symptom duration progression, prior episodes of PID, recent sexual transmitted infections, or recent sexual activity contraceptive use in any recent uterine instrumentation. I specifically ask about gastrointestinal and urinary symptoms because these can overlap in obscure diagnoses.

On exam, I complete an abdominal exam assessing for tenderness to palpation or any guarding. Then I perform a pelvic exam with a speculum for evaluation of any discharge presence and assessing the appearance of the cervix. After this, I would perform a bi-manual exam, assessing for cervical motion tenderness, uterine and adnexal tenderness.

I obtained a pregnancy test to exclude ectopic pregnancy, and I may include labs including a CBC, and a inflammatory markers to assess systemic involvement. And then I would also [00:10:00] perform cervical testing for gonorrhea and chlamydia.

Tubo ovarian abscess represents the most severe manifestation of public inflammatory disease and accounts for a substantial proportion of PID related hospitalizations Amongst patients hospitalized for PID, approximately 15 to 35% are found to have a TOA Classic PID findings are often absent. Up to 40% of patients are afebrile at presentation and approximately 25% have a normal white blood cell count.

Reliance on fever leukocytosis alone, thus leads to mist or delayed diagnosis. Risk factors for TOA can include prior PID, multiple sexual partners and recent uterine instrumentation, but it can also occur in patients without identifiable risk factors. Alright. What imaging are would you obtain and how would you interpret the findings?

I would obtain a transvaginal ultrasound as my first line imaging [00:11:00] modality. I would assess for a complex edex L Mass with irregular thick walls, internal echoes, septations, and loss of normal ovarian architecture. I also evaluate for free fluid. If my ultrasound findings are equivocal or if I'm concerned about any sort of gastrointestinal pathology, I may proceed with a contrast enhanced CT scan as well to better define the extent of disease and adjacent organ involvement.

Ultrasound is typically the initial imaging study due to its availability and safety characteristic. Findings include a multilocular complex NAL mass with internal debris and surrounding inflammatory changes. CT provides superior visualization of the extent of inflammation. CT findings can include rim enhancing and NL collections, fat stranding, thickened fallopian tubes, and bowel wall involvement.

The presence of free intraperitoneal fluid increases concern for an impending or [00:12:00] actual rupture of the TOA. Okay, so once you've arrived at TOA as your diagnosis, what would you do or how would you determine your initial management?

Management for A TOA depends on clinical stability, menopausal status, abscess characteristics in response to therapy.

In a stable, premenopausal patient without signs of rupture or sepsis, I initiate broad spectrum IV antibiotics with close inpatient monitoring. I reassess the patient's pain, vital signs and laboratory trends over the next 40 to 72 hours. Lack of improvement or worsening symptoms may prompt me to escalate to image guided drainage or potential surgical intervention.

Medical management alone is successful in about 65 to 75% of patients with TOA abscess size is the strongest predictor of antibiotic failure. Abscesses measuring seven centimeters or [00:13:00] larger are significantly more likely to require drainage or surgery. Rising inflammatory markers during hospitalization, particularly CRP, can correlate with treatment of failure.

Rupture occurs in roughly 10 to 15% of cases and carries a high risk of sepsis, mandating an immediate surgical intervention. Tell me more about when you might proceed with drainage or surgery.

I proceed with interventions such as drainage or surgery when the patient fails to improve after adequate antibiotic therapy.

Um, or if the patient shows signs of clinical deterioration or has imaging features suggestive of rupture. Image. Guided drainage is preferred when feasible to preserve reproductive organs while surgery is indicated maybe for cases such as rupture, sepsis, or concern for malignancy.

Image guided drainage combined with antibiotics increases treatment success to over 90% in appropriately selected patients and will reduce the [00:14:00] hospital length of stay. Surgical management is required in approximately 20 to 30% of cases. Overall, laparoscopy is preferred when feasible, but laparotomy may be required in unstable patients.

Fertility preservation rates are significantly higher when conservative approaches succeed.

Let's switch gears now. Let's say you have a 28-year-old patient who has sudden onset, severe right lower quadrant pain and vomiting. She denies any fever of vaginal discharge. Talk to me about your approach to this presentation.

For this particular presentation, I'm concerned for potential ovarian torsion, which I treat as a surgical emergency.

I rapidly assess pregnancy status, onset, and characteristics of pain and associated symptoms such as nausea or vomiting. I review prior imaging, no ovarian cyst. Fertility treatments or pregnancy. On exam, I assess for focal tenderness and peritoneal signs, [00:15:00] recognizing that exam findings can be minimal, and sometimes for these patients, I proceed urgently with pelvic ultrasound to support the diagnosis, but I may not delay surgical intervention if clinical suspicion is high.

Ovarian torsion accounts for approximately two to 3% of gynecologic emergencies. Over 80 to 85% of cases are associated with an nexel mass, most commonly benign cysts. Nausea and vomiting occur in the majority of patients and are highly suggestive for the diagnosis. Fever is uncommon, early and suggests necrosis or secondary inflammation.

What ultrasound findings would support torsion, um, and tell me further about what the limitations of ultrasound might be.

When I look in an ultrasound and suspect torsion of the ovary, I would see potential for ovarian enlargement, stromal edema, peripheral follicle displacement, and the twisted vascular pedicle.

When visible, [00:16:00] I may interpret these ultrasound findings cautiously, particularly thinking about doppler flow because normal flow does not exclude torsion.

Ultrasound sensitivity for torsion is approximately 70 to 85% with a specificity around 75%. Ovarian enlargement is the most consistent finding. The Whirlpool sign is highly specific and when identified strongly supports the diagnosis.

Stopper flow is unreliable. More than half of confirmed torsion cases demonstrate a preserved arterial flow due to intermittent torsion or dual blood supply to the ovary. Absent venous flow is more predictive of ischemia than absent arterial flow.

Okay. If you're suspecting torsion, how is it definitively diagnosed and then ultimately managed?

Definitive diagnosis of torsion is made surgically. Given the risk of irreversible ischemia, I proceed to urgent laparoscopy for detorsion when torsion [00:17:00] is suspected in reproductive age. Patients, I prioritize ovarian conservation whenever feasible.

Preoperative diagnostic accuracy remains low with fewer than 50% of cases correctly diagnosed before surgery. Detour is standard management. Even when the ovary appears dusky or emus. Follow-up studies demonstrate recovery of ovarian function and over 80% of salvaged ovaries. Concerns about thrombo embolism following detour have not been supported by evidence.

Is there an instance where you might perform salpingo ectomy instead?

I may perform a nexel removal when the ovary is clearly non-viable or when malignancy is suspected, particularly if I'm operated in a post-menopausal patient.

True ovarian necrosis is uncommon malignancies identified in fewer than 3% of torsion cases overall, but increases [00:18:00] significantly after menopause, detour prior to removal, improves visualization and reduces the incidence of your re injury. Conservative management is associated with lower complication rates and shorter hospital stays.

What is the overarching principle in managing acute nexel pathology?

When I think about overarching principles for managing acute nexel pathology, whether that is uh, TOA or an ovarian torsion, I think about early recognition and timely intervention as being very critical Delays in either increased morbidity, compromise fertility, and worsen outcomes for patients.

Both TOA and ovarian torsion require decisive management. Delays in diagnosis are unfortunately common and directly correlate with increased complications, longer hospitalization, and loss of ovarian function. Maintaining a high index of suspicion and [00:19:00] prioritizing timely intervention will improve outcomes.

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